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Regular Session, 2014 ENROLLED
SENATE BILL NO. 516
BY SENATORS BUFFINGTON, DORSEY-COLOMB, GUILLORY AND MILLS AND
REPRESENTATIVE STUART BISHOP
AN ACT1
To enact Part VII of Chapter 15 of Title 37 of the Louisiana Revised Statutes of 1950, to be2
comprised of R.S. 37:1360.81 through 1360.91, relative to direct primary care; to3
provide for definitions; to provide for prohibitions on discrimination; to provide for4
direct fees; to provide for prohibited and authorized practices; to provide for5
acceptance and discontinuation of patients; to provide exemptions from state6
insurance laws; to provide for business conduct; to provide for annual reports; to7
provide for violations and penalties; to provide for rules and regulations; and to8
provide for related matters.9
Be it enacted by the Legislature of Louisiana:10
Section 1. Part VII of Chapter 15 of Title 37 of the Louisiana Revised Statutes of11
1950, comprised of R.S. 37:1360.81 through 1360.91, is hereby enacted to read as follows:12
PART VII. DIRECT PRIMARY CARE PRACTICE13
§1360.81. Definitions14
For the purposes of this Part, the terms stated in this Section have the15
meanings assigned to them, respectively, unless the context otherwise requires:16
(1) "Board" means the Louisiana State Board of Medical Examiners.17
(2) "Direct agreement" means a written agreement entered into between18
a direct practice and an individual direct patient, the parent or legal guardian19
of the direct patient, or a family of direct patients whereby the direct practice20
charges a direct fee as consideration for being available to provide and21
providing primary care services to the individual direct patient. A direct22
agreement shall describe the specific health care services the direct practice will23
provide and be terminable at will upon written notice by the direct patient.24
(3) "Direct fee" means a fee charged by a direct practice as consideration25
for being available to provide and providing primary care services as specified26
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in a direct agreement.1
(4) "Direct patient" means a person who is party to a direct agreement2
and is entitled to receive primary care services under the direct agreement from3
the direct practice.4
(5) "Direct patient-provider primary care practice" and "direct5
practice" means a physician, group, or entity that meets the following criteria:6
(a) Is any of the following:7
(i) A physician who provides primary care services through a direct8
agreement.9
(ii) A group of physicians who provide primary care services through a10
direct agreement.11
(iii) An entity that sponsors, employs, or is otherwise affiliated with a12
group of physicians who provide primary care services only through a direct13
agreement, which entity is wholly owned by the group of physicians or is a14
nonprofit corporation exempt from taxation under Section 501(c)(3) of the15
Internal Revenue Code and is not otherwise regulated under Title 22 of the16
Louisiana Revised Statutes of 1950. Such entity shall not be prohibited from17
sponsoring, employing, or being otherwise affiliated with other types of health18
care providers not engaged in a direct practice.19
(iv) "Direct patient-provider primary care practice" or "direct practice"20
shall not include an organization or an entity that contracts with a primary care21
practice for the provision of research, technological, operational, and22
administrative support, but such an entity or an organization does not provide23
a direct medical care service.24
(b) Enters into direct agreements with direct patients or parents or legal25
guardians of direct patients.26
(c) Does not accept payment for health care services provided to direct27
patients from any entity subject to regulation under Title 22 of the Louisiana28
Revised Statues of 1950.29
(d) Does not provide, in consideration for a direct fee, services,30 SB NO. 516 ENROLLED
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procedures, or supplies such as prescription drugs except as provided in R.S.1
37:1360.84(B), hospitalization costs, major surgery, dialysis, high level2
radiology, including but not limited to X-ray computed tomography, positron3
emission tomography, magnetic resonance imaging, or invasive radiology,4
rehabilitation services, procedures requiring general anesthesia, or similar5
advanced procedures, services, or supplies.6
(6) "Health insurance issuer" means an entity subject to the insurance7
laws and regulations of this state or subject to the jurisdiction of the insurance8
commissioner that contracts or offers to contract or enters into an agreement9
to provide, deliver, arrange for, pay for, or reimburse any of the costs of health10
care services, including a sickness and accident insurance company, a health11
maintenance organization, a preferred provider organization, or any similar12
entity, or any other entity providing a plan of health insurance or health13
benefits.14
(7) "Physician" means a natural person who is the holder of an15
allopathic (MD) degree or an osteopathic (DO) degree from a medical college16
in good standing with the board who holds a license, permit, certification, or17
registration issued by the board to engage in the practice of medicine in the18
state of Louisiana.19
(8) "Primary care" means routine health care services, including20
screening, assessment, diagnosis, and treatment for the purpose of promotion21
of health, and detection and management of disease or injury.22
§1360.82. Prohibition on discrimination23
Except as provided in R.S. 37:1360.85, no direct practice shall decline to24
accept any person solely on account of race, religion, national origin, the25
presence of any sensory, mental, or physical disability, education, or economic26
status.27
§1360.83. Direct fee28
A. A direct practice shall charge a direct fee on a periodic basis. The29
amount of the fee and the periodic basis upon which such fee shall be paid shall30 SB NO. 516 ENROLLED
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be included in the provisions of the direct agreement. The fee shall represent the1
total amount due for all primary care services specified in the direct agreement2
and may be paid by the direct patient or on his behalf by others.3
B. A direct practice shall maintain appropriate accounts and provide a4
history of payments and services received upon a request of a direct patient.5
C. If a direct patient chooses to pay more than one periodic direct fee in6
advance, the funds shall be held in a trust account and paid to the direct7
practice as earned at the beginning of each period. Any unearned direct fees8
held in trust following receipt of termination of the direct agreement shall be9
promptly refunded to the direct patient.10
D. A direct fee schedule applying to an existing direct patient may not be11
increased over the annual negotiated amount more frequently than annually.12
A direct practice shall provide advance notice to existing patients of any change13
within the fee schedule applying to those existing direct patients. A direct14
practice shall provide notice of any change in the fee not less than sixty days15
from the date of the change.16
§1360.84. Prohibited and authorized practices17
A. A direct practice shall not:18
(1) Enter into a participating provider contract with any health19
insurance issuer or with any health insurance issuer's contractor or20
subcontractor to provide health care services through a direct agreement except21
as set forth in Subsection B of this Section.22
(2) Submit a claim for payment to any health insurance issuer or any23
health insurance issuer's contractor or subcontractor for health care services24
provided to direct patients as covered by their agreement.25
(3) With respect to services provided through a direct agreement, be26
identified by a health insurance issuer or any health insurance issuer's27
contractor or subcontractor as a participant in the health insurance issuer's or28
any health insurance issuer's contractor or subcontractor network for purposes29
of determining network adequacy or being available for selection by an enrollee30 SB NO. 516 ENROLLED
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under a health insurance issuer's benefit plan.1
(4) Pay for health care services covered by a direct agreement rendered2
to direct patients by providers other than the providers in the direct practice or3
their employees, except as described in Subsection B of this Section.4
B. A direct practice and provider may:5
(1) Enter into a participating provider contract with a health insurance6
issuer for purposes other than payment of claims for services provided to direct7
patients through a direct agreement. Such physicians shall be subject to all8
other provisions of the participating provider contract applicable to9
participating providers, including but not limited to the right to:10
(a) Make referrals to other participating providers.11
(b) Admit the carrier's members to participating hospitals and other12
health care facilities.13
(c) Prescribe prescription drugs.14
(d) Implement other customary provisions of the contract not dealing15
with reimbursement of services.16
(2) Pay for charges associated with:17
(a) The provision of routine lab and imaging services.18
(b) Dispensing, at no additional cost to the direct patient, of prescription19
drugs prescribed by the direct provider in accordance with state law and20
regulations promulgated by the board.21
(3) Charge an additional fee to direct patients for supplies, medications,22
and specific vaccines provided to direct patients that are specifically excluded23
under the agreement, provided the direct practice notifies the direct patient of24
the additional charge, prior to their administration or delivery.25
§1360.85. Acceptance or discontinuation of patients; third-party payments26
A. A direct practice shall not decline to accept new direct patients or27
discontinue care to existing patients solely because of the patient's health status.28
A direct practice may decline to accept a patient if the practice has reached its29
maximum capacity, or if the patient's medical condition is such that the30 SB NO. 516 ENROLLED
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provider is unable to provide the appropriate level and type of health care1
services in the direct practice. As long as a direct practice provides a patient2
notice and the opportunity to obtain care from another physician, a direct3
practice may discontinue care for a direct patient if any one of the following4
conditions is satisfied:5
(1) The patient fails to pay the direct fee under the terms required by the6
direct agreement.7
(2) The patient has performed an act that constitutes fraud.8
(3) The patient repeatedly fails to comply with the recommended9
treatment plan.10
(4) The patient is abusive and presents an emotional or physical danger11
to the staff or other patients of the direct practice.12
(5) The direct practice discontinues operation as a direct practice.13
B. Subject to the restrictions established in this Part, a direct practice14
may accept payment of direct fees directly or indirectly from third parties. A15
direct practice may accept a direct fee paid by an employer on behalf of an16
employee who is a direct patient. However, a direct practice shall not enter into17
a contract with an employer relating to direct practice agreements between the18
direct practice and employees of that employer other than to establish the19
timing and method of the payment of the direct fee by the employer.20
C. Subject to the restrictions established in this Part, a direct practice21
may accept payment of direct fees directly or indirectly from the Louisiana22
Medical Assistance Program or any entity contracting with the state of23
Louisiana to provide managed care in the Louisiana Medical Assistance24
Program, subject to any necessary approval from the Centers for Medicare and25
Medicaid Services.26
§1360.86. Direct practice not an insurer27
A direct practice that complies with the provisions of this Part is not a28
health insurance insurer and not subject to the provisions of nor the regulations29
under Title 22 of the Louisiana Revised Statutes of 1950.30 SB NO. 516 ENROLLED
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§1360.87. Conduct of business; prohibitions1
A person shall not make, publish, or disseminate any false, deceptive, or2
misleading representation or advertising in the conduct of the business of a3
direct practice or relative to the business of a direct practice.4
§1360.88. Misrepresenting the terms of a direct agreement5
A person shall not make, issue, circulate, or cause to be made, issued, or6
circulated, a misrepresentation of the terms of any direct agreement, the7
benefits or advantages promised thereby, or use the name or title of any direct8
agreement misrepresenting the nature thereof.9
§1360.89. Direct agreement requirements; disclaimer10
A.(1) A direct agreement shall include the following disclaimer:11
"This agreement does not provide comprehensive health insurance12
coverage. It provides only the health care services specifically described."13
(2) A direct agreement may not be sold to a group and may not be14
entered with a group of subscribers. A direct agreement shall be an agreement15
between a direct practice and an individual direct patient or a family of direct16
patients.17
(3) Nothing shall prohibit the presentation of marketing materials to18
groups of potential subscribers or their representatives.19
B. A comprehensive disclosure statement shall be distributed to all direct20
patients with their participation forms. The disclosure shall inform a direct21
patient of his financial rights and responsibilities to the direct practice as22
provided for in this Part, encourage a direct patient to obtain and maintain23
insurance for services not provided by the direct practice, and state that the24
direct practice will not bill a health insurance issuer for services covered under25
the direct agreement. The disclosure statement shall include contact26
information for the board.27
§1360.90. Rules28
The board may promulgate all rules and regulations that are necessary29
and proper to effectuate the provisions of this Part.30 SB NO. 516 ENROLLED
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§1360.91. Violations1
Violations of this Part shall constitute unprofessional conduct and2
subject violators to any and all sanctions which may be pursued by the board3
pursuant to R.S. 37:1285.4
PRESIDENT OF THE SENATE
SPEAKER OF THE HOUSE OF REPRESENTATIVES
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED: